Amateur Radio Emergency Service

Radio Amateur Civil Emergency Service

Columbia County ARES/RACES Application Form

 

Name: _________________________________________ Call: _______________

 

Address: _________________________________________________________________________________

 

City: ______________________________________ State: ____________ Zip Code: _____________________

 

Home Phone: __________________Business Phone: _________________ Cell/Pager: __________________

 

License Class: _________________ Primary Radio Interests: _______________________________________

 

Other Professional Licenses or Certifications: ___________________________________________________

Email address: _____________________________________________________________________________

 


Check bands and modes you can operate:

Band

160

80

60

40

30

20

17

15

12

10

6

2

222

440

FM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

RTTY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SSB

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MOBILE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PACKET

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PORTABLE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Which of the following items are available to you?

Reliable transportation

 

Portable battery power

 

4 wheel drive vehicle

 

Portable generator

 

RV trailer or motor home

 

 

 

What ICS training and certification have you received? ____________________________________________________

In what kind of disaster experiences have you participated? ________________________________________________

Do you hold a current first aid card?  YES_____              NO _____

 

 


The following information is required by the Oregon Emergency Management Department, to obtain a state ARES/RACES photo ID card.  This card is mandatory to be able gain entry to secure emergency facilities such as the EOC, 911, Fire and Police stations or disaster sites for providing auxiliary radio communications.  All information is strictly confidential and is for the purpose of the mandatory background check conducted by the Sheriff’s Office.  Columbia County and the State of Oregon is dual ARES and RACES membership.  All information will be carefully guarded and not used for any other purpose than a background check for a State of Oregon identification card.

 

Full legal name: _____________________________________________ Call sign: ___________________

 

Date of Birth: __________________ ODL or ID #___________________ SSN#:______ - ____ - _________

 

Hair Color: _____________ Eyes: ____________ Height: __________ Weight: ________lbs     

 

DPSST#:_________________________                                   ARES/RACES Identification Card Number: ______

                (Public safety personnel only)                                                                                                                      (If any)

 

Signature: ________________________________________________________ Date: ________________

 


Please mail to David Morrisson, Columbia County ARES/RACES, 58605 Kavanaugh, St., Helens, OR  97051

A downloadable form is available at http://www.colemer.org/ARES.htm or email form to: w7or@arrl.net.